New Patient Medical History

New Patient Registration

Please fill in the form below
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Sex *
Last 4 of Social Security Number: *
Occupation / Job *
If none, put none
Contact Number: *

Area Code Phone Number
Preferred Method of Contact (you can select more than 1) : *

Phone Call Text Email
E-mail
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Vision Insurance:

(Please fill out using the Subscriber's Information)
Vision Insurance (Select the following): *

Vision Service Plan (VSP) EyeMed Davis Vision CalOptima (through VSP) Spectera MES Vision
Subscriber Name: *
Subscriber ID: *
If don't know, put unknown
Subscriber's Date of Birth:
Subscriber's Last 4 of SSN: *
Relationship to Patient
Medical Insurance:

(Please fill out using the Subscriber's Information)
Insurance Company:
Subscriber ID:
Subscriber Date of Birth:
Reason for Visit: *
Do you smoke? *

No Yes
If yes, please state how much (i.e. 1 cigarette per day)?
Are you being treated for any medical condition? *

No Yes
If yes, please list:
If don't know, put unknown.
Are you allergic to any medications, including eye drops? *

No Yes
If yes, please list:

Do you or any blood relatives have the following?

Self

Father

Mother

Siblings

Grandparents

Diabetes

High Blood Pressure

High Cholesterol

Macular Degeneration

Glaucoma

Asthma

Lung Disease

Heart Disease

Thyroid Problems

Seasonal Allergies

Insurance & Medical Record Release Authorization
Name *

First Name Last Name
Authorization

I hereby give my consent to the doctors, staff and associates of Ikeda Optometry to provide eye care services to me and/or my family. I understand and agree that I am responsible for the balance of the account. I acknowledge that by presenting myself or my child as a patient, I consent for vision and medical care by Dr. John Ikeda and the staff of Ikeda Optometry. I hereby grant full authority to Dr. John Ikeda and respective assistants to administer and perform any and all drugs, treatments, tests, or diagnostic procedures to or upon me, which may be advised or necessary.
Responsible Party's Signature:

Clear
Insurance Assignment & Release

I, the undersigned (or my dependent), have insurance coverage and assign directly to Ikeda Optometry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of this signature on all insurance submissions (including future submissions).
Responsible Party's Signature:

Clear
Authorization of Medical Release

I authorize Ikeda Optometry to obtain my medical records on my behalf from any previous medical/ocular exams. Please release my past medical record in it's entirety to Ikeda Optometry when requested.
Responsible Party's Signature:

Clear
DateTime
Should be Empty:

New Patient Registration